The amount of fitness instructors who experience voice issues that continue to recur is 44-70%, according to Rumbach 2013. 78% report feeling a change in their voices after teaching just one class. And the very sad thing is that 80% of these folks regularly use microphones, but they constantly malfunction or the instructor has no idea how to use them efficiently.

If you're like me, we have the disease of being busy. I have caseloads, business opportunities, blogs, family, taxes, billing, and as my head starts to spin, I could go on for days. In the past, I have waited for specific CEU's to roll around that I knew would be applicable to my patient demographic. Sometimes this would put me in a tough situation where I would have to spend money on airfare and hotels just to get certified in something that was voice or swallow related.

MedBridge and I have partnered to offer quality CEU's at a very discounted rate so you can afford to educate yourself in the areas of knowledge specific to what you treat. MedBridge has observed that dealing with overpriced CEUs is a constant issue with SLPs (among other disciplines) and they have created a website that offers online continuing education and patient engagement tools. These video courses are accredited and contain excellent research based approaches.

No longer do you have to travel to get CEU's (unless you want to, of course) and no longer do you have to shell out big bucks to do so! Since running my own business, all my CEU courses have been my financial responsiblity, and last year I spent over $1,000 for a course I attended in person. The year before that, it was a little less than $600 for an online certification in my area of specialty. NO MORE! Medbridge is offering a special pricing discount so you can earn your CEU's anywhere at anytime. (PJ's and coffee encouraged!)

MedBridge has hundreds of CEU courses, live webinars and is an ASHA Approved CE provider. Use Promo Code: atempoVOICECENTER or click here to get your own discounted annual subscription to MedBridge for only $95! That's saving you $175 right away.

You also get exclusive access to the home exercise program builder (HEP) which allows you to customize exercise programs specifically for your patients with over 5,000 video exercises. HEP's can be easily printed, texted or shared online. This means your patient is more likely to adhere to your home program, know what is expected and make progress. That's really what it's all about.

Students? It's even better for you! If you use the student promo code: ATEMPOVOICECENTERstudent you will have a yearly subscription at only $75! Remember, you must sign up with your email address ending in ".edu" for this to be honored. You still get everything in the yearly regular SLP membership, except for CEU credit, because you aren't eligible to earn until you have your license.

The best part is that huge names in the voice community have recorded webinars that are available to you 24/7! This means voice gurus like Joseph Stemple, Edie Hapner, Mary Sandage, Robert Grider, Sarah Schneider, and even Julie Barkmeier-Kraemer sharing valuable and applicable knowledge. If you are a Many Hats SLP, you can expand your knowledge in many other areas. Plus MedBridge is adding more every day.

I hope you'll take advantage of this fantastic offer, because you shouldn't feel like you are just getting CEU's to fill your quota. You should have affordable options to learn about areas specific to you. This benefits you as a clinician and most of all, your patients.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Working for yourself is not an easy out. It takes dedication and learning how to sift through the murky waters to pull through to the sun above. You can enjoy, but you have to keep trying to get ahead. If you want a 9-5 where you leave it all at work, I would encourage you to re-think working your own business. As for me, I couldn't imagine it any other way....

As a graduate student in Speech-Language Pathology, there are so many names to learn about with regard to terms coined, rehabilitation techniques researched and therapy approaches we don't even use anymore. As a patient, you just want answers. Terminology is important, and Christina Kang, Joseph Hentz, and Dr. David Lott have pioneered a term to describe symptoms for dysphagia that does not show up routine swallow studies.

Kang and team took a retrospective look at folks who came into their clinic for swallow and laryngeal studies including VFSS and flexible laryngoscopy. VFSS stands for Videofluroscopic Swallow Study, or Modified Barium Swallow Study, which looks at the swallow function under x-ray with the patient drinking and eating barium. The important thing here is that no swallow weakness or organic pathology was observed in these tests. This means there was no structural cause for the patient complaints. 97% of the patients chosen for this study that were complaining of swallow issues, also had abnormal laryngeal muscle tension. 82 percent had laryngeal hyperresponsiveness. This means that the larynx would respond to stimuli even when it wasn't present, like in refractory chronic cough, paradoxical vocal fold motion and globus sensation. Inflammation, or swelling and irritation, was also found in 52% of these people.

Credit: Kang et al 2016 article.

Kang thought, what if we targeted muscle tension in the larynx through voice rehabilitation, to see if these symptoms resolved? So, 13 of the initial 67 attended voice therapy sessions that specifically focused on unloading muscle tension. Treatments consisted of a combination of Resonant Voice Therapy, Semi-occluded vocal tract exercises, diaphragmatic/low breathing and cirumlaryngeal massage.

Guess What? ALL 13 reported a complete resolution of dysphagia symptoms! Why is this so exciting? I don't know about you, but these patients seem to get pushed to the side if VFSS shows nothing abnormal, but the patient still feels symptoms. The most common symptom sometimes during my week at the clinic is, "I feel like something is stuck in my throat." Having complaints seemingly dismissed after a diagnostic test that shows no problems can make the patient upset, feel like it's "all in my head" and lead to continued and unnecessary testing and physician visits. Kang and team are proposing Muscle Tension Dysphagia or "MTDg" to describe a certain group of patients with functional dysphagia.

The important and amazing thing here is that these patients improved! There is a possible solution to the problems that brought them to the doctor in the first place. We no longer have to send these patients away with no option for treatment.

Of course further testing is needed in this area, but what a great treatment option to offer patients who normally just get sent home and told to "stop worrying about choking, you'll be fine."

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

What Kittie Verdolini Abbott likes to call the "Scream Study" shows just that. She and her cohorts (including Ryan Branski and Clark Rosen) took a group of 9 folks and subjected them all to the same task to "tax" their vocal fold tissue (talking loudly for 1 hour, with a few small breaks in between). Then, they separated them into 3 groups.

Fast-forward to your awesome new job, but after the newness wears off, you are stuck with seemingly unattainable productivity goals, or IEP's goals that just will absolutely never end. You may feel pressure to qualify a student or patient for therapy.

I've enjoyed hearing feedback from you all about short term goals and how they work for you. Many of you are more specific in creation, but are focused on the same end goal. If you have no idea what I'm talking about, check out Part I of this series about Short Term voice rehabilitation goals.

Let's get to chatting about goals for the Long Term. Perhaps you abandoned some goals in the Short Term that were no longer appropriate. Maybe your patient has met all the Short Term goals and has a dramatically improved quality of life. This may be the perfect time to complete final acoustic measures, possibly a re-videostroboscopy, and a Vocal Handicap Index.

Long Term

(1) Patient will demonstrate voice production abilities which meet the needs for activities of daily living while maintaining health of true vocal folds within 12 weeks as evidenced by patient report and SLP observations. (I have 12 weeks, because I always guess that 9-12 weeks is long enough for a patient to come to 4-6 sessions, with illness, no-shows and cancellations. Is your patient able to talk for work? Is the fatigue or throat pain lowered or eradicated completely?)

(2) Patient will decrease or eliminate pathology while improving overall health of true vocal folds by eliminating vocal misuse within 12 weeks as evidenced by patient report and SLP observations. (Misuse is not only throat clears, coughs and yelling, but pressed talking, or talking for long periods of time with no break. Singing, and especially voice use after the show, is another area of misuse that should have been addressed and fixed before this goal is met.)

(3) Patient will maximize efficiency of the vocal mechanism relative to existing laryngeal disorder through coordinating subsystems of voice within 12 weeks as evidenced by patient report and SLP observations. (This is an expansion of STG #5, and this target voice should be present across your patient's speaking patterns. Diagnosis is important here, as it can sometimes be appropriate to have LTG 2 & 3 for a patient, but sometimes it's one or the other. For example, if a patient has vocal nodules, LTG 2 only would be appropriate. If the patient has Muscle Tension Dysphonia in response to a vocal cyst, both may be appropriate because you want to decrease or eliminate the MTD, but the patient may or may not be a surgical candidate for the cyst to be removed, so that disorder would remain existing. And sometimes, you get lucky and the excrescence goes away with voice rehabilitation alone!)

(4) Patient will achieve improved/normal voice assessed with perceptual scales, acoustic and/or aerodynamic measures within 12 weeks. (Using the CAPE-V, AVQI, VHI, Cepstral Peak Prominence, you can track progress for your patient and also help back up your data for insurance reimbursement. I mean, who doesn't like to see tangible progress that is quantitative? By the way, Cepstral Peak Prominence (CPP) is considered the most promising and robust way of determining severity of a dysphonia....that's right, more than Jitter...more than Shimmer......)

(5) Patient will return to vocal activities of daily living with reduction and/or elimination of complaints regarding vocal production within 12 weeks as evidenced by patient report and SLP observations. (Your patient sometimes will come in and meet this goal, without having met all the short term goals, and you have no choice but to say hooray for you, and you never see that person again. It know it's hard, since you didn't finish your plan of care as you initially indicated, but this was the outcome we were looking for! The patient is happy, you shouldn't just keep them on case to fill boxes.)

(6) Patient will acquire vocalization skills to meet personal and professional needs while maintaining and improving health of true vocal folds as evidenced by patient report, as measured by improvement in acoustic measures, and as assessed through videostroboscopy and through perceptual analysis. (You may delete this or combine it with #5, but it could stand on its own as well. Patient report and your skilled clinical assessment are both important factors here.)

(Special thanks to SLP's Kim Coker, Chis Watts and Shelby Diviney, as I drew from their teachings and materials to formulate the Short and Long term goals listed in this blog series. Thanks to them both for being my mentors and guiding me in being the clinician I strive to be.)

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

I have had inquiries from multiple sources about how I track progress in voice rehabilitation sessions, so I thought it was high-time that I sat down to create a blog post about what types of goals I use in my sessions and how you can tweak them to make it workable for your specific clients. (Read up on Part 2 of this series on Long Term Voice Rehabilitation Goals.)

I divide my goals up into banks, one for Short Term and one for Long Term. I'll discuss Long Term goals in part 2 of this blog series. The Short Term goals are mostly appropriate for each patient, depending on if the patient has water intake restrictions.

Short Term

(1) Patient/Client will demonstrate an understanding of voice production physiology and controlled voice utilization by describing/listing the phonation process and alternatives or modifications of current use in different environmental contexts with 90% accuracy within 4 weeks. (I measure this by education via video, picture and demonstration with biofeedback, to help the client better understand their own mechanism, so they have better control of their own ability to produce sound. This is also where I like to have the patient claim responsibility for the voice disorder, and stop referring to "the voice" in the third person, like it has power.)

(2) Patient will confirm implementation of hydration regimen in 3 consecutive sessions/weeks to decrease viscosity of reported throat mucus and irritation - as self-reported by patient with 100% accuracy. (There is not a published study about the specific amount of water best for the body, but a good rule of thumb is 8 glasses per day or 1/2 your body weight in ounces. Limiting alcohol and caffeine are also part of this goal, which you could technically create 2 separate goals for.)

(3) Patient will eliminate vocal overuse to improve health of vocal folds by reducing or eliminating trauma to vocal tissues within 4 weeks as evidenced by patient report and SLP observations with 100% accuracy. (This is a great one to help focus the patient on a better vocal atmosphere, and you can dovetail goal 1 into this one as well.)

(4) Patient will establish volitional control of respiration evidenced by utilization of diaphragmatic breathing during structured tasks within 4 weeks with 100% accuracy independently. (The basis of proper technique requires abdominal support, so this goal will be the one I work very diligently on during the first session and onward. The patient will have a challenging time if this goal is not mastered before beginning sound production.)

(5) Patient will coordinate vocal subsystems in hierarchical speech tasks by producing sound in an efficient manner yielding improved or normal voice quality and vocal endurance in the presence of existing laryngeal disorder with 90% accuracy independently. (This goal is very important, and the patient must reach this goal before number 7 can be achieved. Vocal Resonance, Flow Phonation and Semi-Occluded Vocal Tract Exercises can all be used to achieve this.)

(6) Patient will reduce vocal effort and fatigue by decreasing upper body tension as evidenced by a decrease in symptoms and lack of observable/palpable signs of hyperkinetic muscular behaviors. (I palpate my patients on the shoulders, neck, jaw, base of tongue and larynx to determine baseline tension and rate on a 0-3 scale with 3 begin severe tension. I monitor progress in these areas by what I feel and what I can see visually as the patient phonates or sits at rest.)

(7) Patient will implement generalization of goals with 80% accuracy independently to encourage the use of new vocal skills in varied speaking contexts. (This includes in sentences, paragraphs, conversation, with ambient background noise, while being masked with an audio source in headphones, on the phone, at the checkout counter.....Wherever the patient uses the voice, this goal applies. You can separate it out if you like, especially if your client is a child, but for adults this should take usually between 4-6 sessions.)

I hope this was helpful, and stay tuned for the blog post on Long-Term Goals for your Voice Rehabilitation clients! I'd love to hear how you are creating your voice goals, so feel free to comment below!

(Special thanks to SLP's Kim Coker and Shelby Diviney, as I drew from their teachings and materials to formulate the Short and Long term goals listed in this blog series. Thanks to them both for being my mentors and guiding me in being the clinician I strive to be.)

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Charting at the time of patient care is vital to my ability to provide quality services. If I wait too long, my notes aren’t as detailed and I forget to notate everything I did in a session with a patient. I refer to each previous session to know how to proceed and I like referring to my goals for each patient EVERY SESSION so I make sure I’m on the right track. Electronic charting has truly changed my life. I type relatively quickly and like that I can pre-populate phrases I use often, and can customize. .
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. 👚: @dickiesuniforms . 💇🏼‍♀️: @britanymarshallbeauty
#slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

Where do I begin? Of the 30 years you’ve been in this earth, I’ve been lucky to be present for the last 12 of them. I can’t even count all the memories and I tried my best to collect some of them in pictures from the span of time I’ve called you friend. Crazy times, beautiful times, sad times and hard times. I love you @bionda_saraphine. You are my person. Happiest of birthdays to you. We were lucky to celebrate with you last night.

When you get off work early and you’re still in your #DickiesMedical scrubs, you get on your knees in the onion patch with the original Dickies wearer in the family! I mean, the man has been wearing these jumpsuits since I can remember. He may be 99, but he still stays as active as ever. Remember all my website photos of the gray haired man looking at his #vocalfolds? That’s the legend! How did you spend your afternoon?
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#brandambassador #ad #slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

Been wondering about what is best practice for voice evaluations? What is the bare minimum you can scoot by with? Check out @speech_science’s podcast featuring Kristie Knickerbocker from A TEMPO Voice Center talking what is most important and what's the deal with videostroboscopy! bit.ly/Episode26Voice
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When your voice colleagues @dr.bernard.rousseau & @branskir come to town for an @aahconsulting presentation, you do what any normal person would do....you meet at your #crossfit box @crossfitpanthercity! Sorry it wasn’t an amrap to get us moving, but you guys knocked out some pretty impressive strict hand stand pushups 😉 If you haven’t checked out the great things they’re doing with speechandhearingprofessionals.com, you should sneak a peek 👀 .
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The beautiful @stacypepp popped in today for the most generous gift of SATB sheet music from her church in Pampa. It’s like glorious boxes of this stuff! 😍 I will be needing this for something big coming soon, and it couldn’t have come at a better time. Thank you so much Stacy, my 💜 is full! #gofrogs .
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Serendipity: A chance encounter. So, a few days ago, I made an online sale of my #confidentclinician video to an SLP from my hometown. I will admit to Facebook stalking her because it seemed coincidental that she was from #bearcat country. Fast forward to this evening, when after a busy clinic day, the fam and I made it to @presscafefwtx for some dinner. And who should be there also? Wearing black #scrubs? 👯‍♀️@mc_richter that’s who! What a small 🌎! And here’s to many more chance encounters! .
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#slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

How often should you be hydrating?

Get in the habit of drinking half of your body weight in ounces of water each day. I label my water bottles with times I must drink a certain amount by. Get a nifty looking reusable bottle to help keep you motivated.

Cough Drops?

Try Breezers by Halls. They do not contain menthol or eucalyptus. Those ingredients can contribute to chronic cough.

Vocal Abuse Tip

Instead of yelling from room to room at home, bring the communication partner closer to you when communicating.

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No portion of this website is intended to diagnose or treat any medical problem. It is meant to help further understanding of voice and swallow related issues. Please make an appointment with a licensed Speech Language Pathologist or Physician for assessment.